Provider Demographics
NPI:1194797407
Name:WACIUMA, JOHN L (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:WACIUMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6122
Mailing Address - Country:US
Mailing Address - Phone:715-717-6600
Mailing Address - Fax:
Practice Address - Street 1:900 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6122
Practice Address - Country:US
Practice Address - Phone:715-717-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43260208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1985253OtherHIGHMARK BLUE SHIELD
MN440057700Medicaid
PA822242OtherFIRST PRIORITY HEALTH
PA118832Medicare PIN
MN440057700Medicaid
PA1985253OtherHIGHMARK BLUE SHIELD
B74733Medicare UPIN